Objective: The purpose of this case report is to describe the utilization of Cox Manual Cervical Distraction for the treatment of cervicalgia in a patient with Diffuse Idiopathic Skeletal Hyperostosis (DISH).

Intervention and Outcome: This patient was treated with Cox manual cervical distraction resulting in a decrease in the severity and frequency of her pain and improved ability to perform ADLs. Protocol II was utilized to help promote normal facet mobility.

Conclusion: This case study describes the treatment of a 59 year old woman with chronic neck pain in the setting of DISH.

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a spinal and extraspinal articular disorder characterized by ligamentous calcification and ossification. This entity is distinct from ankylosing spondylitis and degenerative joint disease and occurs with an incidence of 12 percent in the United States, affecting middle-aged and elderly individuals. It is also known as Forrestier’s disease, spondylosis hyperostotica, spondylitis ossificans ligamentosa, and senile ankylosing hyperostosis.1

Numerous studies have documented the efficacy of flexion-distraction manipulation applied to the lumbar spine for the treatment of conditions including disc herniation2, radiculopathy3, stenosis4,5, synovial cysts6, post-surgical continued pain3, and pregnancy-related pain7.

Cox flexion-distraction tables which include the cervical headpiece allow for treatment of the cervical spine. This component facilitates manual axial distraction as well as motion in flexion, extension, rotation, lateral bending and coupled movements. These movements are primarily designed to reduce intradiscal pressure and restore normal physiologic ranges of motion. Manual distraction is a type of spinal traction wherein the doctor directly controls the application of force in terms of both amplitude and vector.8

Treatment of this type for the cervical spine has been documented in case reports and retrospective studies. Improvement has been observed in cases of radiculopathy caused by cervical disc herniation9,10,11 as well as in cases involving cervical stenosis12, degenerative disc disease13, adjacent segment disease related to congenital anomalies14, and surgical fusion.15

The purpose of this case report is to present a case of cervicalgia treated with Cox manual cervical distraction in a patient with Diffuse Idiopathic Skeletal Hyperostosis.

Clinical Presentation

A 59 year-old female presented to a private chiropractic practice with complaints of constant neck pain and stiffness of gradual onset over the past five years. She described all neck movements as painful, limiting her ability to perform activities of daily living (ADLs) such as driving, lifting, reading, and desk work, and resulting in disordered sleep. She described the quality of her neck pain as throbbing, aching, and stiff, with radiation to her upper back and shoulders bilaterally. She rated her pain as an 8 out of 10 on an 11-point Numeric Rating Scale. Her Neck Disability Index (NDI) was rated at 36%. She denied any radiation of pain past the shoulder and denied any numbness, tingling, or weakness of the upper extremity.

Prior interventions included an evaluation by a rheumatologist who diagnosed Fibromyalgia and degenerative disc disease. She was prescribed medication including Lyrica and Desipramine which she took for years but discontinued as she perceived no benefit. She was also prescribed physical therapy which she discontinued due to a lack of progress.

Active cervical range of motion examination revealed the following: flexion and extension limited to 25 degrees and provocative at end range, right and left rotation limited to 40 degrees with mild provocation at end range, right lateral flexion limited and provocative at 20 degrees, and left lateral flexion limited to 25 degrees, causing a pulling sensation in the contralateral trapezius. Palpation revealed tenderness over the articular pillars from C3-7. Myotomes and dermatomes were tested and intact at C5-T1. Myotatic reflexes were rated at 2+ bilaterally. Tromner’s sign was absent. Hypertonicity to palpation was noted at the suboccipital, upper and middle trapezius, levator scapulae, rhomboids and splenius capitus muscles bilaterally.

A-P lower cervical, lateral cervical, and cervicothoracic lateral plain film radiographs were performed. A right list was noted in the coronal plane. Sagittal plane alignment demonstrated an anterior head carriage. A mild loss of intervertebral disc space with uncinate proliferation was noted at C4-C5 and C5-C6. Extensive anterior vertebral body osseous proliferation was seen extending from C3 through C6 that spanned the anterior surface of the intervening disc space. The intervertebral body heights and atlanto-dental interspace were within normal limits with no evidence of osseous pathology. The radiographic impressions included minor multilevel degenerative disc disease, uncovertebral arthrosis at C4-C5 and C5-C6, and diffuse idiopathic skeletal hyperostosis (DISH).

Figure 1: A-P lower cervical plain film radiograph

Figure 2: Lateral Cervical plain film radiograph

Figure 3: Cervicothoracic lateral plain film radiograph

Treatment Intervention

Treatment consisted of Cox manual distraction manipulation applied to the cervical spine. Due to the absence of a radicular component to the patient’s subjective and objective presentation, Cox protocol II was used. The initial 3 treatments consisted of 10 repetitions of axial decompression contacting the occiput. On the fourth visit, coupled movements of axial decompression and rotation were performed to spinal levels C2 through C6 where the treating physician palpated somatic dysfunction with suboptimal intersegmental rotation. Subsequent visits included the addition of coupled motions of axial distraction with lateral flexion and rotation to the upper thoracic spine with the aim of restoring normal physiologic motion to those segmental levels.

This patient was treated eight times over the course of four weeks and demonstrated progressive subjective and objective improvement. Outcome measures were collected upon completion of the course of care, at which time the patient rated her pain at 4/10 on a Numeric Rating Scale and endorsed a Neck Disability Index of 22%. This was an improvement of 50% and 39% respectively.

Discussion

Clinical characteristics of DISH are similar to degenerative joint disease including joint stiffness, typically worse in the morning, and low grade musculoskeletal pain especially of the spine. Approximately 20% of patients complain of dysphagia due to compression of the esophagus from anterior cervical spine osseous proliferation. Extraspinal complaints may also be present since osseous proliferation may occur in any ligamentous or tendinous attachment to bone.1

Radiographic features of the vertebral column show calcification followed by ossification of the anterior longitudinal ligament (ALL) typically beginning in the middle of the vertebrae extending to bridge the adjacent vertebral disc. This flowing exuberant hyperostosis, often over one centimeter in thickness, causes the appearance of a bumpy anterior spinal contour and may be described as “Candle Flame” hyperostosis. Initially the deep layers of the ALL may be uninvolved resulting in a vertical radiolucent shadow. This lucency may be obliterated as the ligamentous ossification progresses. Calcification may be inhibited due to anteriolateral fibrous discal extensions from the outer annular fibers. This may result in horizontal radiolucent linear clefts.1 In the cervical spine the bony hyperostosis is most exuberant in lower segments (C4-7). There is relative preservation of intervertebral disc height, although minor disc degeneration may be present, and a lack of significant apophyseal joint arthrosis which may allow for relatively normal vertebral motion. A slight to moderate loss of the cervical lordosis and increase in thoracic kyphosis is common.16

Though patients with DISH may present with stiffness and decreased range of motion due to altered biomechanics, it remains unclear whether or to what degree DISH is associated with pain.17 Holton et. al. report that few studies have evaluated the association of DISH and back pain. The objective of Holton’s study was to estimate the prevalence of radiographic DISH in the thoracic and lumbar spine among elderly men and determine its association with back pain in the last 12 months. The findings indicated that those with DISH experienced less frequent and less severe back pain than counterparts without DISH. 18

Few published studies document the management of patients with DISH with chiropractic manipulation. Roberts et. al. demonstrated subjective and objective improvement utilizing Activator-assisted spinal manipulative therapy in a 74 year-old man with low back pain and a history of degenerative disc disease and DISH. 19 Hoffman reports on four cases of men over the age of 75 with DISH and associated neurological signs and symptoms. Symptoms often appeared to be minimal compared to the dramatic radiographic changes. Three of the four patients responded favorably to chiropractic spinal manipulation.20 Troyanovich reported on a 60 year-old man with DISH and a history of episodic disabling low back pain. Treatment consisted of chiropractic manipulation including drop table adjustments, exercise and standing lumbar traction. The patient demonstrated improvement with respect to flexibility, pain severity, and engagement with activities of daily living lasting at least 19 months.21

In this case, the patient was treated with protocol II of Cox manual cervical distraction. Protocol II is utilized to treat patients presenting with neck pain and associated non-radicular pain with the aim of restoring physiologic ranges of motion. Treatments begin with axial distraction, followed by a combination of distraction with rotation and lateral flexion as clinically indicated.22

There is a growing body of evidence to suggest that manual cervical distraction utilizing a Cox headpiece may induce physiologic changes. These changes may be responsible for the symptomatic relief reported for patients affected by discogenic or facetogenic pain conditions. Gudavalli, et. al. measured changes in intradiscal pressure when performing manual cervical distraction using the Cox headpiece. Pressure transducers were inserted into the nucleus pulposus at the C4-5, C5-6, C6-7, and C7-T1 discs of cadavers using an anterior surgical approach. Intradiscal pressure decreases were found in the levels tested during manual distraction, more prominently in y-axis distraction and flexion.23

Joachim reported symptomatic improvement of neck pain with pain and numbness radiating to both hands in a patient with spondylotic myelopathy and a history of cervical spine plate fusion at C6-C7.15 Cox has also demonstrated relief from pain associated with disc degeneration coupled with advanced facet osteoarthritic degeneration.25 Allen has documented successful treatment using Cox spinal manipulation for the treatment of a patient with a C6-C7 disc herniation, foraminal narrowing, and associated radiculopathy.26

Limitations

Because this is a single case report, it is not appropriate to generalize the effects from this patient to others with neck pain and findings of DISH. A larger scale study would be needed to make any determination regarding safety or efficacy of the applied intervention. Also, the long-term effects of care for this patient are not reported.

Conclusion

This case study describes the treatment of a 59 year old woman with radiographic findings of DISH and concomitant chronic neck pain that responded favorably to utilization of Cox manual distraction.

Competing interests

The authors declare that they have no competing interests. Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of Veterans Affairs or the US Government.

Objective: The purpose of this case report is to describe the utilization of Cox Manual Cervical Distraction for the treatment of cervicalgia in a patient with Diffuse Idiopathic Skeletal Hyperostosis (DISH).

Intervention and Outcome: This patient was treated with Cox manual cervical distraction resulting in a decrease in the severity and frequency of her pain and improved ability to perform ADLs. Protocol II was utilized to help promote normal facet mobility.

Conclusion: This case study describes the treatment of a 59 year old woman with chronic neck pain in the setting of DISH.

Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a spinal and extraspinal articular disorder characterized by ligamentous calcification and ossification. This entity is distinct from ankylosing spondylitis and degenerative joint disease and occurs with an incidence of 12 percent in the United States, affecting middle-aged and elderly individuals. It is also known as Forrestier’s disease, spondylosis hyperostotica, spondylitis ossificans ligamentosa, and senile ankylosing hyperostosis.1

Numerous studies have documented the efficacy of flexion-distraction manipulation applied to the lumbar spine for the treatment of conditions including disc herniation2, radiculopathy3, stenosis4,5, synovial cysts6, post-surgical continued pain3, and pregnancy-related pain7.

Cox flexion-distraction tables which include the cervical headpiece allow for treatment of the cervical spine. This component facilitates manual axial distraction as well as motion in flexion, extension, rotation, lateral bending and coupled movements. These movements are primarily designed to reduce intradiscal pressure and restore normal physiologic ranges of motion. Manual distraction is a type of spinal traction wherein the doctor directly controls the application of force in terms of both amplitude and vector.8

Treatment of this type for the cervical spine has been documented in case reports and retrospective studies. Improvement has been observed in cases of radiculopathy caused by cervical disc herniation9,10,11 as well as in cases involving cervical stenosis12, degenerative disc disease13, adjacent segment disease related to congenital anomalies14, and surgical fusion.15

The purpose of this case report is to present a case of cervicalgia treated with Cox manual cervical distraction in a patient with Diffuse Idiopathic Skeletal Hyperostosis.

Clinical Presentation

A 59 year-old female presented to a private chiropractic practice with complaints of constant neck pain and stiffness of gradual onset over the past five years. She described all neck movements as painful, limiting her ability to perform activities of daily living (ADLs) such as driving, lifting, reading, and desk work, and resulting in disordered sleep. She described the quality of her neck pain as throbbing, aching, and stiff, with radiation to her upper back and shoulders bilaterally. She rated her pain as an 8 out of 10 on an 11-point Numeric Rating Scale. Her Neck Disability Index (NDI) was rated at 36%. She denied any radiation of pain past the shoulder and denied any numbness, tingling, or weakness of the upper extremity.

Prior interventions included an evaluation by a rheumatologist who diagnosed Fibromyalgia and degenerative disc disease. She was prescribed medication including Lyrica and Desipramine which she took for years but discontinued as she perceived no benefit. She was also prescribed physical therapy which she discontinued due to a lack of progress.

Active cervical range of motion examination revealed the following: flexion and extension limited to 25 degrees and provocative at end range, right and left rotation limited to 40 degrees with mild provocation at end range, right lateral flexion limited and provocative at 20 degrees, and left lateral flexion limited to 25 degrees, causing a pulling sensation in the contralateral trapezius. Palpation revealed tenderness over the articular pillars from C3-7. Myotomes and dermatomes were tested and intact at C5-T1. Myotatic reflexes were rated at 2+ bilaterally. Tromner’s sign was absent. Hypertonicity to palpation was noted at the suboccipital, upper and middle trapezius, levator scapulae, rhomboids and splenius capitus muscles bilaterally.

A-P lower cervical, lateral cervical, and cervicothoracic lateral plain film radiographs were performed. A right list was noted in the coronal plane. Sagittal plane alignment demonstrated an anterior head carriage. A mild loss of intervertebral disc space with uncinate proliferation was noted at C4-C5 and C5-C6. Extensive anterior vertebral body osseous proliferation was seen extending from C3 through C6 that spanned the anterior surface of the intervening disc space. The intervertebral body heights and atlanto-dental interspace were within normal limits with no evidence of osseous pathology. The radiographic impressions included minor multilevel degenerative disc disease, uncovertebral arthrosis at C4-C5 and C5-C6, and diffuse idiopathic skeletal hyperostosis (DISH).

Figure 1: A-P lower cervical plain film radiograph

Figure 2: Lateral Cervical plain film radiograph

Figure 3: Cervicothoracic lateral plain film radiograph

Treatment Intervention

Treatment consisted of Cox manual distraction manipulation applied to the cervical spine. Due to the absence of a radicular component to the patient’s subjective and objective presentation, Cox protocol II was used. The initial 3 treatments consisted of 10 repetitions of axial decompression contacting the occiput. On the fourth visit, coupled movements of axial decompression and rotation were performed to spinal levels C2 through C6 where the treating physician palpated somatic dysfunction with suboptimal intersegmental rotation. Subsequent visits included the addition of coupled motions of axial distraction with lateral flexion and rotation to the upper thoracic spine with the aim of restoring normal physiologic motion to those segmental levels.

This patient was treated eight times over the course of four weeks and demonstrated progressive subjective and objective improvement. Outcome measures were collected upon completion of the course of care, at which time the patient rated her pain at 4/10 on a Numeric Rating Scale and endorsed a Neck Disability Index of 22%. This was an improvement of 50% and 39% respectively.

Discussion

Clinical characteristics of DISH are similar to degenerative joint disease including joint stiffness, typically worse in the morning, and low grade musculoskeletal pain especially of the spine. Approximately 20% of patients complain of dysphagia due to compression of the esophagus from anterior cervical spine osseous proliferation. Extraspinal complaints may also be present since osseous proliferation may occur in any ligamentous or tendinous attachment to bone.1

Radiographic features of the vertebral column show calcification followed by ossification of the anterior longitudinal ligament (ALL) typically beginning in the middle of the vertebrae extending to bridge the adjacent vertebral disc. This flowing exuberant hyperostosis, often over one centimeter in thickness, causes the appearance of a bumpy anterior spinal contour and may be described as “Candle Flame” hyperostosis. Initially the deep layers of the ALL may be uninvolved resulting in a vertical radiolucent shadow. This lucency may be obliterated as the ligamentous ossification progresses. Calcification may be inhibited due to anteriolateral fibrous discal extensions from the outer annular fibers. This may result in horizontal radiolucent linear clefts.1 In the cervical spine the bony hyperostosis is most exuberant in lower segments (C4-7). There is relative preservation of intervertebral disc height, although minor disc degeneration may be present, and a lack of significant apophyseal joint arthrosis which may allow for relatively normal vertebral motion. A slight to moderate loss of the cervical lordosis and increase in thoracic kyphosis is common.16

Though patients with DISH may present with stiffness and decreased range of motion due to altered biomechanics, it remains unclear whether or to what degree DISH is associated with pain.17 Holton et. al. report that few studies have evaluated the association of DISH and back pain. The objective of Holton’s study was to estimate the prevalence of radiographic DISH in the thoracic and lumbar spine among elderly men and determine its association with back pain in the last 12 months. The findings indicated that those with DISH experienced less frequent and less severe back pain than counterparts without DISH. 18

Few published studies document the management of patients with DISH with chiropractic manipulation. Roberts et. al. demonstrated subjective and objective improvement utilizing Activator-assisted spinal manipulative therapy in a 74 year-old man with low back pain and a history of degenerative disc disease and DISH. 19 Hoffman reports on four cases of men over the age of 75 with DISH and associated neurological signs and symptoms. Symptoms often appeared to be minimal compared to the dramatic radiographic changes. Three of the four patients responded favorably to chiropractic spinal manipulation.20 Troyanovich reported on a 60 year-old man with DISH and a history of episodic disabling low back pain. Treatment consisted of chiropractic manipulation including drop table adjustments, exercise and standing lumbar traction. The patient demonstrated improvement with respect to flexibility, pain severity, and engagement with activities of daily living lasting at least 19 months.21

In this case, the patient was treated with protocol II of Cox manual cervical distraction. Protocol II is utilized to treat patients presenting with neck pain and associated non-radicular pain with the aim of restoring physiologic ranges of motion. Treatments begin with axial distraction, followed by a combination of distraction with rotation and lateral flexion as clinically indicated.22

There is a growing body of evidence to suggest that manual cervical distraction utilizing a Cox headpiece may induce physiologic changes. These changes may be responsible for the symptomatic relief reported for patients affected by discogenic or facetogenic pain conditions. Gudavalli, et. al. measured changes in intradiscal pressure when performing manual cervical distraction using the Cox headpiece. Pressure transducers were inserted into the nucleus pulposus at the C4-5, C5-6, C6-7, and C7-T1 discs of cadavers using an anterior surgical approach. Intradiscal pressure decreases were found in the levels tested during manual distraction, more prominently in y-axis distraction and flexion.23

Joachim reported symptomatic improvement of neck pain with pain and numbness radiating to both hands in a patient with spondylotic myelopathy and a history of cervical spine plate fusion at C6-C7.15 Cox has also demonstrated relief from pain associated with disc degeneration coupled with advanced facet osteoarthritic degeneration.25 Allen has documented successful treatment using Cox spinal manipulation for the treatment of a patient with a C6-C7 disc herniation, foraminal narrowing, and associated radiculopathy.26

Limitations

Because this is a single case report, it is not appropriate to generalize the effects from this patient to others with neck pain and findings of DISH. A larger scale study would be needed to make any determination regarding safety or efficacy of the applied intervention. Also, the long-term effects of care for this patient are not reported.

Conclusion

This case study describes the treatment of a 59 year old woman with radiographic findings of DISH and concomitant chronic neck pain that responded favorably to utilization of Cox manual distraction.

Competing interests

The authors declare that they have no competing interests. Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of Veterans Affairs or the US Government.